Provider Demographics
NPI:1669400990
Name:MOORE, DANIEL (PA)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 PINE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34119-3900
Mailing Address - Country:US
Mailing Address - Phone:239-263-0849
Mailing Address - Fax:239-263-2376
Practice Address - Street 1:680 2ND AVE N
Practice Address - Street 2:SUITE 304
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5753
Practice Address - Country:US
Practice Address - Phone:239-261-7711
Practice Address - Fax:239-262-0176
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2019-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101574363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL970020475OtherMEDICARE RR
FLY00ZNOtherBCBS OF FL
FL970020475OtherMEDICARE RR
FLY00ZNOtherBCBS OF FL